This video demonstrates phacoemulsification surgery in an 88-year-old man with
pseudoexfoliation and a dense lens. Trypan blue was painted on the capsule to help in better visualization. kuglen iris hooks were used to stretch the small pupil. A single-piece foldable IOL was implanted to avoid stress on the already weak zonules.

Surgeon: Dr. Stephen Lane, University of Minnesota

Transcript

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DR LANE: This is an 88-year-old gentleman who has pseudoexfoliation. You can see the pseudoexfoliation material on the capsule. And a pretty dense lens. And so of course the two challenges with pseudoexfoliation is is the potential for loose zonules, and the pupil is small. So I’m gonna start out, as I always do, with two paracenteses, because here I probably will use bimanual INA, because of the potential for lax zonules. And because it’s a fairly dense lens, I think it will be difficult for you to see. I’m going to use a little Trypan blue in this case, to help visualize the capsule. And I like to paint this on a little bit by rubbing it on the surface, rather than just squirting it in. So once again, I used this to hold onto the edge of the cornea, to steady the eye and hold it. Again, more important in topical. I make a shallow groove, probably a third of the thickness, and then go in at its base, angle up, and then enter. And I’m gonna use a little bit more Viscoat. And now I’m going to take two Kuglen hooks, and I just wanted to demonstrate — you know, this is sort of a borderline small pupil. And so this is an easy way of stretching the pupil. And so you can avoid having to use a ring. There was a little synechia here that we broke. But you can see that we enlarged the pupil pretty significantly. And so, once again, just to create your own capsulorrhexis forceps, and you can make it however you want to… We’re gonna start in the center of the pupil. And the VisionBlue will make this easier for you to see. And you want to get it turned over, as you see here. And we’re gonna try and make this rhexis a little bit bigger than I typically would, simply because we want a little more room to manipulate this, because of the potential of the loose zonules. The one thing that also happens with pseudoexfoliation is there tends to be more anterior capsular phimosis. So the anterior capsule shrinks more. And so if you make a small capsulorrhexis, you could end up with an anterior capsular opening that’s 2 or 3 millimeters. This way, as the capsule might shrink down from phimosis, you’ve got a large enough capsulorrhexis that that won’t be an issue. In these more dense lenses, I’ll actually use the viscoelastic to hydrodissect a little bit. So rather than use fluid right away, I’m going to go in and create a little space under the capsule with the viscoelastic, because this is a pretty dense lens. And so we’ll slide underneath there. And you can see it wanted to pop up, so we just pushed it down. But, once again, you can see it rotates nicely. And that’s what you want. You want to make sure that the lens rotates before you go in and start your phaco. And once again, I’m gonna show a little bit more needle than I bet you’re used to seeing, because it helps to get into the trough to make the chops. And I know my rhexis is about the size of the pupil. So I don’t have to worry too much about catching the anterior capsulorrhexis, as long as I stay away from the pupil. And so I’m gonna turn the port down in a traditional fashion, and we’ll go ahead and do a stop and chop. I think this is the best way to learn phaco, when you’re starting with this technique, rather than just go to chop. So we’re gonna create a trough. So you try and make the trough about two tip diameters wide. And, again, we want to be as gentle on the zonules as we can, because this is a case of pseudoexfoliation. So I’ve got my chopper now in the other hand, and we’re gonna go all the way to the bottom. So you go all the way to the base. And then you would make your crack. And I can see that it’s all the way through. Now I’m just gonna make another little wedge. Just like cutting a piece of pie or a piece of pizza. See? We just go down. Doesn’t have to be real far out. And then we’re just gonna break that. We just want one little piece. We’ve got a little wedge there. And if you want, you can kind of go in and just bring it forward with your chopper. Watch the tip of my phaco. I’m not gonna chase that around. I’m gonna use my second instrument to get it into the right spot. And now we’ve removed that quadrant. Now there’s room for the pieces to move inside the bag. And I’m gonna switch my hand position. Because I’ve got small hands. I can’t do it with one hand. I’m gonna put in my second instrument. I’m gonna put this right next to that. I’m gonna burrow in. A little bit of phaco. And now stay on the vacuum. And you can see the piece will pull out. You can see it. And now you can chop it. And then you eat it up. And now half the lens has been removed. Now we’re gonna go ahead and rotate the lens. And once again, look at my phaco tip. It doesn’t move. The only thing that’s moving is my second hand. Engage a little phaco. You can pull it out a little bit. Expose it. And just chop it. And now you can remove that piece. And what’s left is about half of a half. And so now it’s all been removed. You can take out your second instrument. And so now I’m gonna use bimanual. And why bimanual here? Again, there’s loose zonules, potentially. So I want to do something that’s very gentle. And using bimanual, even though it’s gonna take just a slight bit longer to do it this way, is a safer way to do this. And so, again, just very easy. To strip out the cortex. With minimal stress on the zonules. And then we’ll just get the subincisional. The zonules appear to be in good shape. So there’s not… And we’ll just deepen the lens. This is Provisc. This is hyaluronate. I’m just putting this in the capsular bag. And so now we’ll put the lens in. I like to use these single-piece lenses for these cases with potentially loose zonules, because there’s not as much stress on them to place them. And so one thing I think that’s important, as you develop your phaco techniques, is to do things pretty much the same way every single time. So, once again, you just go in on irrigation. And so we’ll just remove the viscoelastic from the front part. And then we just kind of nudge it, and we can sneak right up underneath it. And remove the viscoelastic from behind it. We’ll hydrate the incisions. Hydrate the roof. And then the paracenteses, which oftentimes leak more than the… And, once again, I always like to just sort of seat the lens. I’m just pushing down on it a little bit, to make sure it’s well back and in the bag before I leave.